August 16, 2011

Modern Medicine vs. Alternative Medicine: Different Levels of Evidence

Prescription medicines and advances in medical treatment have helped people avoid disability and death caused by disease, lowered overall treatment costs, and has lowered death rates for heart disease, stroke, cancer, and other deadly diseases for several decades.

Since 1970, the death rate from heart disease has dropped nearly 60% and deaths from stroke are down 70%. The death rate from cancer has dropped 16% since 1990 and the death rate from HIV/AIDS has dropped more than 75% from its highest point in 1995. In addition, the average life span of Americans increased from 69.7 years in 1960 to approximately 80 years in 2007.

In addition, the 5-year survival rates for cancer have risen by 26% just since 1984. And while HIV/AIDS was the 8th leading cause of death in the US in 1996, today, it’s not even ranked in the top 15.

Moreover, for every $1 spent on statin therapy for heart attack survivors, as much as $9.44 is produced in health gains. For every $1 spent on routine use of beta-blockers for acute heart attack sufferers, as high as $38.44 is produced in health gains. And for every $1 spent on intensive glycemic control in newly diagnosed type 2 diabetes patients, as much as $3.77 is produced in health gains.

The use of newer inhaled corticosteroids for patients (including children) for one year has also reduced the risk of hospitalization by 50%, the number of outpatient visits by 26%, and monthly health care costs by 24% per patient. Additionally, because of the treatments and medicine researched and developed by the pharmaceutical industry, early detection and better treatments have increased overall 5-year cancer survival rates by 36% since the late 1970s. Moreover, life expectancy for people with cancer increased 3 years between 1980 and 2000, and 86% of that gain is attributed to better treatment, including medicines.

Despite the significant gains in health care and quality of living individuals have experienced over the past several decades because of the treatments and drugs created by industry (in collaboration with academia and government), a recent article in The Atlantic conveniently disregards the above data in favor of the “triumph of new-age medicine,” also known as “alternative medicine.”

Specifically, the article asserts that the medical community is growing more open to alternative medicine’s possibilities in large part because “mainstream medicine is failing.” But is it failing? Based on the statistics above, this point is extremely misguided and problematic.

New-Age Medicine

The article focuses on Brian Berman, a physician who is in charge of The Center for Integrative Medicine at the University of Maryland Medical Center in downtown Baltimore. His clinic is focused on alternative medicine, sometimes known as “complementary” or “holistic” medicine.

While there is no official list of what alternative medicine actually comprises, treatments falling under the umbrella typically include acupuncture, homeopathy (the administration of a glass of water supposedly containing the undetectable remnants of various semi-toxic substances), chiropractic, herbal medicine, Reiki (“laying on of hands,” or “energy therapy”), meditation (now often called “mindfulness”), massage, aromatherapy, hypnosis, Ayurveda (a traditional medical practice originating in India), and several other treatments not normally prescribed by mainstream doctors.

The term integrative medicine refers to the conjunction of these practices with mainstream medical care. Interestingly, Berman’s clinic is “hardly unique,” and in recent years, the U.S. has seen about 43 clinics spring up at major academic medical institutions including Harvard, Yale, Duke, the University of California at San Francisco, and the Mayo Clinic.

Alternative-medicine experiences can vary widely. It can include a long initial meeting covering many details of the patient’s history; a calming atmosphere; an extensive discussion of how to improve diet and exercise; a strong focus on reducing everyday stress; an explanation of how the treatment will unleash the body’s ability to heal itself; assurance that over time the treatment will help both the problem that prompted the visit and also general health; gentle physical contact; and the establishment of frequent follow-up visits.

To some however, such as Steven Salzberg, a prominent biology researcher at the University of Maryland at College Park, alternative medicine is merely “cleverly marketed, dangerous quackery.” He asserted that, “these clinics throw together a little homeopathy, a little meditation, a little voodoo, and then they add in a little accepted medicine and call it integrative medicine, so there’s less criticism.”

Contrary to this approach, Salzberg asserted that there is only “one type of medicine, and that’s medicine whose treatments have been proven to work.” And he pointed out that alternative medicine has not been proven to work, and proponents of the practice will not admit it because “they are making too much money on it.”

Accordingly, Salzberg believes that funding for alternative medicine, such as that received by Berman’s clinic, should be removed. Instead, however, he asserted that alternative medicine keeps being propelled by a handful of members of Congress who are determined to see their faith in alternative medicine validated.

In addition, medical centers are lining up to establish research clinics so that they can take NIH funding for alternative-medicine studies. Aggressive marketing of these clinics can also generate substantial patient demand (even a small integrative clinic can take in several million dollars a year).

Salzberg also pointed out that the successful claims of alternative medicine are misguided because subjective symptoms like pain and discomfort are susceptible to the power of suggestion. These same symptoms also tend to be cyclical, meaning that people who see a practitioner when their symptoms flare up are likely to see the symptoms moderate, no matter what the practitioner does or doesn’t do. Patients simply misattribute the improvement to the treatment.

Consequently, Salzberg noted that the biggest danger of alternative medicine is that patients who see alternative practitioners will stop getting mainstream care altogether. He noted that, “the more time they spend getting fraudulent treatments, the less time they’ll spend getting treatments that work and that could save their lives.”

Alternative Medicine vs. Modern Medicine

About 40 percent of Americans have tried some form of alternative medicine at some point, and some $35 billion a year is spent on it. A certain amount of abuse seems like a given. Nonetheless, says Salzberg, the bottom line is that studies clearly show alternative medicine simply does not work. And at first glance, that contention seems nearly incontrovertible.

The scientific literature is replete with careful studies that show, again and again, that virtually all of the core treatments plied by alternative practitioners, including homeopathy, acupuncture, chiropractic, and others, help patients no more than do “sham” treatments designed to fool patients into thinking they’re getting the treatment when they’re really not.

In contrast to alternative medicine, “modern medicine was formed around successes in fighting infectious disease,” says Elizabeth Blackburn, a biologist at the University of California at San Francisco and a Nobel laureate. “Infectious agents were the big sources of disease and mortality, up until the last century. We could find out what the agent was in a sick patient and attack the agent medically.”

The medical infrastructure we have today was designed with infectious agents in mind. Physician training and practices, hospitals, the pharmaceutical industry, and health insurance all were built around the model of running tests on sick patients to determine which drug or surgical procedure would best deal with some discrete offending agent. The system works very well for that original purpose, against even the most challenging of these agents—as the taming of the AIDS virus attests.

Yet, medicine’s triumph over infectious disease brought to the fore the so-called chronic, complex diseases—heart disease, cancer, diabetes, Alzheimer’s, and other illnesses without a clear causal agent. Now that we live longer, these typically late-developing diseases have become by far our biggest killers. Heart disease, prostate cancer, breast cancer, diabetes, obesity, and other chronic diseases now account for three-quarters of our health-care spending. “We face an entirely different set of big medical challenges today,” says Blackburn.

“But we haven’t rethought the way we fight illness.” That is, the medical establishment still waits for us to develop some sign of one of these illnesses, then seeks to treat us with drugs and surgery. Instead, the author asserts that the drugs created to treat these chronic diseases have been largely inadequate or worse, pointing to examples such as Avastin and Avandia. As a result, the author tries to draw the connection between a few shortcomings to the fact that America spends “vastly more on health as a percentage of gross domestic product than every other country—40 percent more than France, the fourth-biggest payer.” But what the author fails to realize is that of the percentage we are spending on health care, only 10% or 10 cents out of every dollar is coming from prescription drugs or treatments.

Nevertheless, the author asserts that what is needed is a system that focuses on lowering the risk that these diseases will take hold in the first place. “We need to prevent and slow the onset of these diseases,” according to Blackburn. For those proponents of alternative medicine, they espouse getting doctors to speak to patients about healthy diets, encouragement of more exercise, and measures to reduce stress.

The author goes on to cite evidence that “lifestyle and attitude changes have enormous impact on health is now overwhelming.” For example, the article points out Dean

Ornish, a physician-researcher at the University of California at San Francisco and the founder of the independent Preventive Medicine Research Institute, who has been showing in studies for more than three decades that diet, exercise, and stress reduction can do a better job of preventing, slowing, and even reversing heart disease than most drugs and surgical procedures.

To get patients to follow this “alternative regiment,” physicians have to give patients more attention, meaning longer, more frequent visits that focus on what is going on in a patient’s lives; more effort spent easing anxieties, instilling healthy attitudes, and getting patients to take responsibility for their well-being; and concerted attempts to provide hope. In other words, conveying to patients that a physician’s commitment to caring for them will endure over time, and to imbue patients with “trust, hope, and a sense of being known.”

Of course, given the current status of payments, reimbursement, and other medical practice issues, it is difficult for doctors to have visits with patients lasting more than 20 minutes. Moreover, studies show that visits average about 20 minutes, that doctors change the subject back to technical talk when patients mention their emotions, that they interrupt patients’ initial statements after 23 seconds on average, that they spend a single minute providing information, and that they bring up weight issues with fewer than half their overweight patients.

Is Alternative Medicine Effective

Steven Novella calls the notion that alternative care’s benefits are rooted in closer practitioner-patient interactions the “touchy feely defense.” Novella, a highly respected Yale neurologist, argued that claims about the practitioner-patient relationship are only intended to draw attention away from the fact that randomized trials have by and large failed to show that alternative treatments work better than placebos.

In response to this argument, Ted Kaptchuk, a Harvard researcher who studies the impact of placebos, noted that, “mainstream medicine uses the placebo effect all the time.” To be approved by the FDA, a drug has to do better than a placebo in studies.” Consequently, the author points to a recent study, which concluded that 85 percent of new prescription drugs hitting the market are of little or no benefit to patients. But what does that mean?

There are very few “new prescription drugs.” More to the point however, the propaganda about lifestyle changes being better than drugs and devices would be believable if lifestyle changes happened. But Americans are getting fatter and lazier all the time, yet, according to economist Frank Lichtenberg, we’re living longer and better.

With systemic costs in mind, it does not even really make sense to ask physicians—who, after all, spend hundreds of thousands of dollars and a decade of their lives becoming trained in anatomy, biochemistry, high-tech diagnosis, pharmacology, and more—to spend long blocks of time bonding with patients. Other sorts of professionals could be better at the healing, bonding, and placebo-selling part, and for less money.

These might include behavioral-medicine therapists, social workers, nurse practitioners, or even some entirely new sort of practitioner specially trained for the task—and working alongside or under the direction of a conventional physician, who could continue to focus on quickly prescribing conventional tests, drugs, and surgeries when they were specifically called for.

Interestingly, the author pointed out that randomized clinical trials are not needed to prove the effectiveness of alternative medicine. Why? Because physicians are able to prescribe products off-label for indications that also do not have good randomized-trial data. Accordingly, the author asserted that while “we may not have great evidence that alternative medicine works, that’s very different from saying it doesn’t work.”

The problem with this assertion is that if you promote a product off label, you are sued by the Department of Justice for billions of dollars, but if you promote alternative medicine without evidence there are little or no consequences.

Conclusion

There is no question that physicians who spend more time with patients and listen more carefully will see benefits. Novella agreed that a caring, bonding practitioner is more likely to get patients to adopt healthier lifestyles, and that these changes lead to better health. And he agrees that many patients do feel better when practitioners actively try to help them deal with vague, hard-to-diagnose complaints such as pain and fatigue, instead of telling them that there’s no diagnosis or effective treatment.

But these aspects of a better patient-practitioner relationship should not be uniquely associated with alternative medicine, and such principles should not attempt to discredit the breakthroughs and innovations from the drug and device industry. Instead, we should look to our doctors to be the nurturing caregivers who take the time to listen to us, bond with us, and guide us toward healthier lifestyles and lower levels of stress. But for doctors outside of academia, this kind of time is hard to come by. Why?

The current system makes it nearly impossible for most doctors to have the sort of relationship with patients that would best promote health. The biggest culprit, is the way doctors are reimbursed. “Doctors are paid for providing treatments, not for spending time talking to patients,” says Victor Montori, an endocrinologist at the Mayo Clinic.

As pharmaceutical companies begin to take more and more of their business to other countries, along with tax revenues, jobs, and discoveries, journalists should be more careful with how they portray the significant breakthroughs and innovations the pharmaceutical and medical device industry have created for Americans. Mainstream medicine is nowhere close to failing. The American health care system is what is failing Americans, while industry is continuing to put more and more money into research and development to find new cures and treatments for chronic diseases and serious illnesses.

If it were not for the discoveries of these companies, many of the people reading the Atlantic as well as this blog would not be here today. The efforts of the industry should not be sacrificed for the ideals of better care from physicians. As noted above, changes in care are more about the reimbursement system, and less about the 10 cents of every dollar spent on health care in America.

Ultimately, if it were not for the declines in death rates from heart disease and stroke, created by the drug device industry, we would lose 1 million more Americans every year. Just ask yourself, what are the chances that you or someone you loved would be in that 1 million, this year or the next.

Comments

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Alternative? ... alternative to whom is never involve in the others culture or knowledge.
Its impossible to those who did not knowabout to judge (the )others culture or belives. Nevertheless if they were professors in modern sscinces!
In Islamic relgion there were some Definitives structions , it governs - among other things - the diseases & the way of getting rid of it - as-shifaa . Here comes Herbs & Bees Honey , as stratigic safe ,rich, sources to all medicaments as well as nutrition.
Here comes the golden say:( The best medicine, is that covers nutrition needs , and the best food, is that covers medication needs.)
Historically for both mankind& his livestock, nothing stands for both nutrition&medication like what herbs dose!
Finally , Bees honey deveoped out of herbal sources!

If others are of nothing in such belifth or knowledge,this will not means the current medicine is the best or the bioneer one ,For Islamic culture historically came first ...
But the progress,preference or Excellence will cot be of fair justice valus if other compititors are excluded.